I’m currently in Johannesburg waiting to travel home to Perth after spending a few days in Nairobi, Kenya providing Reproductive Health training to field workers from an emergency humanitarian relief organization. On my way to Kenya it suddenly dawned on me the significance of the name of my blog: Midwifery Beyond Borders. There is an incredible shortage of midwives with global experience who can support and encourage skilled birth attendants SBA in low to middle income countries where the maternal death rates are highest. I am certainly stepping beyond my borders and into areas I never thought I would, even could step into.
I’m also starting to see a pattern in the type of work I do. Throughout my life, even as a small child, there has always been a restlessness with the status quo: I can see how things can be done better or see a gap for a new program, new intervention, new idea, new way of doing something. I remember as a young adult struggling with this; as a woman in my thirties, wondering why I could never just be happy with how things were and accept them; and now in my forties starting to creatively accept that this just who I am. Inevitably my new way of thinking or doing something, rubs people the wrong way, especially people or authorities that are keen to maintain the status quo! I’ve always had a strong sense of social justice and speaking up for those who don’t have a voice, even when it means confronting those in authority. This has not been easy, and many times I have recoiled in fear and trembling! The driving force for me is the fact that God is sovereign, above rulers and authorities on Earth, and if He opens a door for me to move through, I know that I can trust Him to give me the courage and the boldness to speak truth and speak up for those vulnerable people. My favourite verse is Jeremiah 1:9, ‘Have I not commanded you? Be strong and courageous. Do not be afraid; do not be discouraged, for the Lord your God will be with you wherever you go.”
The training that I do is not for people who are in settings where there is good governance, well-structured health services and well qualified health workers. I’m finding that I’m in areas where there is very little: poor leadership, few to no properly skilled birth attendants, hardly any resources in terms of simple equipment to provide a health service, environmental challenges, social inequalities and injustice. Those in authority quote the standard World Health Organisation WHO guideline mantra: “1. All women should give birth with a skilled birth attendant SBA at a health facility. 2. There is little benefit in training traditional birth attendants.”
So what do you do when there are no skilled birth attendants in the area? What do you do when there are no functioning health centres? What happens when there is a natural disaster or war and women don’t have access to health care or a SBA? What about the fact that women are not getting an education, so are not able to be trained as skilled nurses, midwives and doctors? And so the number of qualified health professionals is very low to be able to serve the needs of the community. What about women who have experienced terrible sexual abuse and violence at the hands of men, and then their only option for birth with a SBA is a male attendant? Is that fair? And what about the women who are from minority groups, displaced from their homelands and expected to birth with a SBA who treats them badly…verbally and physically abuses them? These situations are not unique, not unusual, in fact they are the norm for many women in low to middle income countries (and I have to sadly add that this happens in high income countries too!).
Many organisations and governments take a hard line approach to the WHO recommendations and I’ve heard stories where countries ban giving out clean birth kits to traditional birth attendants in remote areas because they don’t want to encourage women to birth at home. And yet there are no other options for them. Is it right that we take a hardline approach to women in trying to get them to birth in a health facility when there are so many obstacles and such poor services? Is it right that we marginalize village birth attendants or lay women attending to pregnant women and blame them for maternal deaths?
I don’t think so. I believe this is a top down approach that violates the rights of women, disregards their concerns and fears, and punishes them for circumstances that in many ways, are out of their control. It also further isolates them and promotes suspicion of modern healthcare. At the heart is the fact that I don’t believe that women want to die in childbirth; they want to survive, they want their babies to survive and thrive. The fact they don’t get to a health facility says more about the poor quality of the service and the attendants than it does about the behavior of the women. There are also many men who don’t want to see their wives die in childbirth and who live with the consequences of losing the mother of their children. Generalised statements about men I don’t believe is helpful either.
In my experience in remote villages of Papua New Guinea, women are desperate for better care in pregnancy and birth. Many men too want to know more so that they can help the women in their villages. When they have travelled to a Health Centre they have been let down: verbally abused, demeaned, sent home, made to wait…sometimes as long as they are close to death and then die (yes, this is true and I have heard many stories of this nature). Now this is not to say that there aren’t any caring health staff out there. There are and I have met them, but I have to say they seem to be in the minority. And, there are not many trained staff either. Many have had little training and little to none continuing professional education or support. Their health facilities are rundown and lack basic necessities such as clean water, soap, even a simple Blood Pressure cuff. I think we need to hear the voices of the caring health staff more…sadly I think they’re silenced.
I heard from a field worker who was in the midst of the Ebola crises in Sierra Leone earlier this year, that when people were in quarantine due to exposure to someone who was ebola positive, not even pregnant women were given care or support during childbirth. They birthed alone in their homes. Not even clean birth kits were distributed and explained. Many pregnant women suffered terribly during this crisis and died.
Women cannot be denied services just because they choose to birth at home (or are forced to birth at home) because there is inadequate healthcare. I believe it is important to start somewhere and that somewhere is building the trust of the women and community in the home. As skilled birth attendants we need to show women care and kindness so that trust and respect in the information we provide grows. We have an obligation to improve the quality of our care and services by improving cleanliness, working hard to improve our knowledge and skills and provide more outreach programs. Getting out amongst the people to increase their education about simple health messages can make a difference. The people feel that you haven’t forgotten them and do care about the state of their health. Myths and untruths can be gently refuted. Key health facts need to be communicated regularly over time. As their knowledge grows about how their bodies work, what is important for a healthy pregnancy and safe birth, when and how to get help, I’ve noticed that their confidence grows and so does trust.
So, caring midwives out there. Who is going to join me to be the voice of the women who have no voice and bring quality care to women of childbearing age in desperate situations?